Prolonged Extracorporeal Membrane Oxygenation and Circulatory Support as Bridge to Lung Transplant

doi:10.1016/j.athoracsur.2008.03.053

The Annals of Thoracic Surgery

Volume 86, Issue 4, October 2008, Pages 1357-1360

https://doi.org/10.1016/j.athoracsur.2008.03.053 Get rights and content

A 38-year-old man with progressive alveolitis secondary to polymyositis was treated for 52 days with venovenous and venoarterial extracorporeal membrane oxygenation as a bridge to bilateral lung transplantation. The patient survived, despite multiple complications, and is now back home with good pulmonary function. He is working part-time nearly 3 years post-transplant. This case shows that long-term extracorporeal lung assist is a viable but demanding alternative for bridging patients to pulmonary transplantation. This case also shows that right ventricular failure necessating conversion to veno-arterial assist does not necessarily predict right ventricular failure post-transplant.

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Prolonged extracorporeal lung assist as a bridge to lung transplantation was successful in this particular case, but the story raises many questions. The worldwide lack of donor organs makes prioritization among the possible recipients crucial. Progressive alveolitis and fibrosis secondary to systemic inflammatory autoimmune disease is an uncommon indication for lung transplantation with variable results [1], although anti-rejection immunosuppressive treatment (including tacrolimus) may be

References (5)

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J Heart Lung Transplant
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Artificial lungs: a new inspiration
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There are more references available in the full text version of this article.

Cited by (55)

Development of an ambulatory extracorporeal membrane oxygenation system: From concept to clinical use
2022, Applications in Engineering Science
Extracorporeal membrane oxygenation (ECMO) is a modality of life support for patients suffering from respiratory and/or cardiac failure. With the advances in membrane oxygenation and pump technology in the last two decades, ECMO has become safer and more durable for clinical use. Along with its overall use, there has been an increase in patients who require long-term ECMO support; either awaiting lung recovery or transplantation. Many of them are awake, participating in physical rehabilitation, and even ambulating while supported on ECMO. While the broader ECMO experience is applied to bed-restricted and mechanically ventilated patients, contemporary studies demonstrated that the artificial respiration provided by ECMO is compatible with freedom from adjunctive mechanical ventilation, ambulation, and exercise. With this in mind, our group set out to develop a novel ambulatory ECMO system to facilitate ambulation in patients supported on ECMO. This paper gives a brief overview of the development of this system, focusing on the journey from a laboratory concept to approval for clinical use by the Food and Drug Administration.
Extracorporeal membrane oxygenation in cardiopulmonary disease of rheumatic conditions: A systematic review
2020, Medicina Clinica
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Most patients received glucocorticoids at different dosing regimens to treat disease flares, except when the risk of infection was considered too great. Immunomodulatory therapies used during ECMO included plasmapheresis5,7–9,18–21 plasma exchange,6,22 endovenous immunoglobulins (IVIg),11,17,19,23 conventional disease modifying antirheumatic drugs (cDMARDs)13 and even cytostatic such as cyclophosphamide(CTX)5,7,8,17,18,20,22,24 or tacrolimus.25 During ECMO therapy, in life threatening situations biologic therapy can be considered, with cases of successful CD 20 depletion7,10,25 or interleukin-1 neutralization11 reported.
Recommendations for the treatment of anti-melanoma differentiation-associated gene 5-positive dermatomyositis-associated rapidly progressive interstitial lung disease
2020, Seminars in Arthritis and Rheumatism
The study aimed to develop evidence-based recommendations for the treatment of rapidly progressive interstitial lung disease (RPILD) associated with the anti-Melanoma Differentiation-Associated Gene 5-positive dermatomyositis (DM) syndrome.
The task force comprised an expert panel of specialists in rheumatology, intensive care medicine, pulmonology, immunology, and internal medicine. The study was carried out in two phases: identifying key areas in the management of DM-RPILD syndrome and developing a set of recommendations based on a review of the available scientific evidence. Four specific questions focused on different treatment options were identified. Relevant publications in English, Spanish or French up to April 2018 were searched systematically for each topic using PubMed (MEDLINE), EMBASE, and Cochrane Library (Wiley Online). The experts used evidence obtained from these studies to develop recommendations.
A total of 134 studies met eligibility criteria and formed the evidentiary basis for the recommendations regarding immunosuppressive therapy and complementary treatments. Overall, there was general agreement on the initial use of combined immunosuppressive therapy. Combination of high-dose glucocorticoids and calcineurin antagonists with or without cyclophosphamide is the first choice. In the case of calcineurin antagonist contraindication or treatment failure, switching or adding other immunosuppressants may be individualized. Plasmapheresis, polymyxin B hemoperfusion and/or intravenous immunoglobulins may be used as rescue options. ECMO should be considered in life-threatening situations while waiting for a clinical response or as a bridge to lung transplant.
Thirteen recommendations regarding the treatment of the anti-MDA5 positive DM-RPILD were developed using research-based evidence and expert opinion.
Lung Transplant in Patients with Connective Tissue Diseases
2019, Clinics in Chest Medicine
Citation Excerpt :
Although few studies have explored this in detail, the number of patients with increased PRA levels was similar in SSc and non-SSc groups in 2 studies.39,42 Fewer reports have studied patients with non-SSc CTDs (see Table 1),48–50 although individual case reports have described successful outcomes.14,15,36 One-year, 3-year, and 5-year survival in patients with non-SSc CTDs is similar to survival in patients with IPF or non-CTD ILDs.
Canada's longest experience with extracorporeal membrane oxygenation as a bridge to lung transplantation: A case report
2015, Transplantation Proceedings
Extracorporeal membrane oxygenation (ECMO) is a method of enabling gas exchange through an external membrane used to treat respiratory failure in critically ill patients. ECMO as a bridge to lung transplantation has been investigated as a potential method of reducing lung transplantation waitlist mortality. Herein we describe a case of ECMO as a bridge-to-lung transplantation for the duration of 35 days, which is the longest documented length of ECMO support before successful transplantation in Canada.
The prospective recipient was a 28-year-old female suffering from stage 4 pulmonary sarcoidosis. Given an acute exacerbation of her chronic respiratory failure, ECMO had to be initiated. She remained on ECMO for 35 days until a suitable set of donor lungs became available. The recipient had a prolonged course in hospital but was successfully discharged home where she continues to have good lung function. She remains alive and well at home 5 months post-transplantation and continues to improve and gain strength.
Our case provides hope that in the future we may be able to expand the population of recipients who may be candidates for lung transplantation. This case adds to the growing literature on the role of ECMO as a bridge-to-lung transplantation with the potential to reduce patient deaths while wait-listed for lung transplantation as well as increase the number of transplantations being performed.
Extracorporeal membrane oxygenation in lung transplantation
2013, Medicina Intensiva
El uso de tecnologías extracorpóreas en el soporte cardiopulmonar se ha extendido en los últimos 20 años. Los dispositivos oxigenador de membrana extracorpóreo (ECMO) son los más utilizados y se emplean desde hace años en los programas de trasplante pulmonar. Sin embargo, hay pocos artículos con series amplias de resultados de ECMO. El empleo del ECMO en el fallo respiratorio, además de otorgar un soporte inmediato de oxígeno en pacientes severamente hipoxémicos y/o acidóticos, proporciona protección pulmonar ya que permite la disminución instantánea en las necesidades de presiones y FiO₂ en el ventilador. Las complicaciones del uso de ECMO han ido minimizándose con las mejoras técnicas que presentan los últimos modelos de las asistencias, pero la insuficiencia renal, las infecciones, hemorragias y las complicaciones vasculares y mecánicas siguen siendo referidas en numerosos trabajos. Existen actualmente menos controversias en el empleo de la asistencia cardiorrespiratoria con ECMO como alternativa para pacientes descompensados que están en lista de espera, para el intraoperatorio y postoperatorio del trasplante pulmonar.
The use of extracorporeal techniques in cardiopulmonary support has spread in the last 20 years. ECMO (extracorporeal membrane oxygenation) devices are the most commonly employed option, and have been used for years in lung transplant programs. Nevertheless, few articles on the results of ECMO involving large numbers of cases have been published to date. The use of ECMO in respiratory failure affords immediate oxygen support in patients with severe hypoxia and/or acidosis, and moreover provides pulmonary protection, since it allows an instantaneous decrease in the ventilator pressure and FiO2 needs. The complications of ECMO have been minimized thanks to the technological improvements found in the latest devices, though renal failure, infections, bleeding, and vascular and mechanical complications are still reported in many studies. At present there is less controversy regarding the use of cardiorespiratory assists with ECMO as an alternative in decompensated patients who are on the waiting list, referred to the intra- and postoperative periods of lung transplantation.

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Case reportProlonged Extracorporeal Membrane Oxygenation and Circulatory Support as Bridge to Lung Transplant

Section snippets

Comment

International guidelines for the selection of lung transplant candidates: 2006 update—a consensus report from the Pulmonary Scientific Council of the International Society for Heart and Lung Transplantation

J Heart Lung Transplant

Artificial lungs: a new inspiration

Perfusion

Case report
Prolonged Extracorporeal Membrane Oxygenation and Circulatory Support as Bridge to Lung Transplant